Purpose

The intake lays the foundation for all medication decisions. It is a detailed conversation that allows us to understand your history, current challenges, and goals before any prescription is written.

What to Expect

• Orientation & Consent – Overview of process, confidentiality, and patient rights.

• Presenting Concerns – A full discussion of your current symptoms, priorities, and what brings you to treatment.

• Psychiatric & Medical History – Previous diagnoses, medication trials, side effects, hospitalizations, medical conditions, allergies.

• Family & Social Background – Genetic risks, support systems, stressors, and protective factors.

• Substance Use Review – Alcohol, nicotine, cannabis, prescription or other substances.

• Mental Status Examination – Structured observation of mood, thought process, cognition, and insight.

• Risk & Safety Assessment – Evaluation of suicide or self-harm risk, paired with safety planning if needed.

• Diagnostic Formulation – Integrating findings into a working diagnosis, consistent with DSM-5.

• Medication Planning – Discussion of appropriate options, risks, benefits, and alternatives.

• Lab Orders (if indicated) – Thyroid, metabolic, or other relevant labs ordered; you may use insurance or self-pay directly through the lab.

Outcome
By the end of your evaluation, you will have a clear diagnostic impression, an initial medication plan (if appropriate), and a roadmap for follow-up care.

Purpose:

Follow-ups are structured check-ins that keep your medication plan safe, effective, and responsive to your needs.

Each visit includes:

• Symptom & Function Review – Mood, sleep, energy, focus, and daily life.

• Medication Monitoring – Benefits, side effects, adherence, and dose adjustments.

• Safety Check – Ongoing review of risk, substance use, and protective factors.

• Lab Review (if needed) – Updates on blood work or monitoring tests.

• Brief Mental Status Exam – Snapshot of mood, thought process, and cognition.

• Plan Refinement – Continue, adjust, or change medications; refill coordination; next steps outlined clearly.

Frequency

• More frequent visits (every 2–4 weeks) at the start or after changes.

• Less frequent (every 1–3 months) once stable, with periodic lab monitoring.